NURSE

ASSESSMENT
Juhlyn Mae Makilang, RN
Training and Development Nurse

1. VITAL SIGNS
DEFINITION:
Indicators of vital body function
WHAT ARE THOSE:
Temperature
Pulse
Respiration
Blood Pressure

VITAL SIGNS
When to Assess:
On admission
Based on policy or drs orders
Anytime when there is a change in
condition
Anytime for loss of consciousness
Before and after invasive procedures
Before and after drug administration

TEMPERATURE
Definition:
Heat of the body
Factors Affecting:
Circadian Rhythms
Age
Gender
Stress
Environmental Temp.

TEMPERATURE
Types of temp range:
Hypothermia
Afebrile
Pyrexia
Hyperpyrexia

TEMPERATURE
Types of fever:
Intermittent
Remittent
Constant
Relapsing

TEMPERATURE
Sites:
Tympanic
Oral
Rectal
Axillary

TEMPERATURE
Normal Range:

PULSE
Definition:
Throbbing sensation
Factors Affecting:
BP
TEMP
OXYGENATION
ACTIVITY
EMOTION
MEDICATION

PULSE
Characteristics:
Rate
Quality
Rhythm

PULSE
Normal Range:
Adult: 60-100
Newborn: 120-160
Children: 70-140
Types:
Bradycardia
Tachycardia

PULSE
Sites:
Peripheral
1. Temporal
2. Carotid
3. Brachial
4. Radial
5. Femoral
6. Popliteal
7. Posterior tibial
8. Dorsalis pedis
. Apical

PULSE
Pulse Deficit:
Apical-radial

RESPIRATION
Definition:
Pulmonary ventilation
Factors Affecting:
Exercise
Disease
Fluids and electrolyte
Medication
Emotion
Age

RESPIRATION

Characteristics:
Eupnia
Tachypnea
Bradypnea
Apnea
Dyspnea
Hyperventilation
Hypoventilation
Cheyne Stokes
Biots

RESPIRATION
Normal Range

Sounds:
Wheeze
Ronchi
Crackles
Friction rub

BLOOD PRESSURE
Definition:
Force of blood
Factors Affecting:
Age
Circadian rhythm
Sex
Diet
Exercise
Weight
Emotion
Body position
Medication

BLOOD PRESSURE
Characteristics:
Hypertension
Hypotension
Orthostatic hypotension
Sites:
Brachial
Popliteal

2. HEALTH HISTORY

Biographical
Chief complaint
History of present illness
Pas medical history
Family history
Lifestyle

3. PHYSICAL ASSESSMENT
CANCER

C- hange in bowel or bladder habit

A- sore that does not heal
U- nusual bleeding or discharge
T- hickening or lump
I- ndigestion or dysphagia
O- bvious change in wart/ mole
N- agging cough or hoarseness

PHYSICAL ASSESSMENT
TECHNIQUES (IPPA):
Inspection
Palpation
Percussion
Auscultation

PHYSICAL ASSESSMENT
Component

Techniques

Parameter

General

Inspection

General
appearance
Hygiene
Posture
Gait
Thought process
Speech
Height
Weight
Vital signs

BMI

PHYSICAL ASSESSMENT
Component

Techniques

Integument

Inspection
Palpation

Parameter
Color
Temp
Texture
Moisture
Lesions
Hair
Nails

SKIN COLOR

Erythema
Cyanosis
Jaundice
Pallor
Vitiligo
Tan

LESIONS

Macule
Patch
Papule
Plaque
Nodule
Tumor

LESIONS

Wheal
Vesicle
Bulla
Pustule

LESIONS

Erosion
Ulcer
Fissure
Crust
Scale
Lichenification

LESIONS

Atrophy
Excoriation
Scar
Keliod

LESIONS

Comedo
Telangiectasia
Nevus

PHYSICAL ASSESSMENT
Component Technique
Head and
Neck

Inspection
Palpation

Parameter
Skull and face:
Shape, symmetry
Neck:
Trachea, Thyroid gland
Eyes:
Visual acuity, Extra
ocular movements
Ears:
Hearing acuity, cerumen
Nose and mouth:
Color, condition,
exudate, tonsils,
tenderness

PHYSICAL ASSESSMENT
Component

Techniques

Parameter

Thorax and
lungs

IPPA

Expansion, rate,
breath sounds
Breast
Nodes

Cardiovascular

IPPA

Pulse,
distention,
sound, murmur

Peripheral

Inspection,
Palpation

Pulse, patency,
color, temp,
hair, lesions,
edema

PHYSICAL ASSESSMENT
Component

Techniques

Abdomen

IAPP

Parameter
Size, shape,
lesion,
distention,
hernia,
tenderness,
bowel sound,

Right Upper Quadrant

Pylorous
Duodenum
Liver
Right Kidney
Right Adrenal
Hepatic Flexure of Colon
Head of Pancreas

Left Upper Quadrant

Stomach
Spleen
Left kidney
Left adrenal
Splenic Flexure of Colon
Body of Pancreas

Right Lower Quadrant

Cecum
Appendix
Right Ovary and FT (f)
Right Ureter and lower kidney
pole
Right Spermatic cord (m)

Left Lower Quadrant

Sigmoid Colon
Left Ovary and FT (f)
Left Ureter and lower kidney
pole
Left spermatic cord (m)

Midline
Urinary bladder
Urethra

PHYSICAL ASSESSMENT
Component

Techniques

Male Genetalia

IP

Parameter
Infestation
CAUTION
Color
Odor

PHYSICAL ASSESSMENT
Component

Techniques

Female
Genetalia

IP

Parameter
Infestation
CAUTION
Color
Odor

PHYSICAL ASSESSMENT
Component

Techniques

Parameter

Anus, Rectum,
Prostate

IP

CAUTION
Stool

Musculoskeletal

IP

ROM
Joints, muscles,
symmetry,
strenght

PHYSICAL ASSESSMENT
Component

Techniques

Neurologic

Parameter
LOC
Memory
Cranial Nerves
Fine motor
Sensory
Reflex

GLASGLOW COMA SCALE

Verbal
Eye opening
Oriented
Spontaneous
Disoriented
To verbal command
Inappropriate
To pain
Incomprehensible
None
Motor
None
To verbal command
To localized pain
Flexes or withdraws
Flexes abnormally
Extends abnormally
None